FL‑45

Ed. 1/92

CHANGE ENDORSEMENT

Refer to Supplemental Declarations if information is not shown on this form.

This endorsement forms part of the policy shown below.

Policy No. Our Name

Your Name:

Address (as shown on Declarations)

Effective Date of Endorsement: Policy Period: from: to:

Agency By:

POLICY CHANGES

1. Amount of Insurance changes:

	A. Residence	B. Related Private Structures	C. Personal Property	D. Additional Living Expense & Loss of Rent	E. Sched. Farm Pers. Prop. Total Amount	E. Blanket Farm Pers. Prop. Total Amount	F. Farm Strcts. Total Amount
From
To

2. Other Changes (Include Endorsement Numbers and Edition Dates).

PREMIUM ADJUSTMENT

Additional Premium Return Premium

Due at Endorsement Effective Date: $ $

N.Y.S. Fire Premium Fee (if applicable) $ $

REVISED INSTALLMENT PAYMENTS (Applies to three-year installment policies).

Dates Due	Original Installments	Increase	Decrease	Revised Installments
	$	$	$	$
	$	$	$	$
Total Premium to Policy Expiration		$	$
N.Y.S. Fire Premium Fee (if applicable)		$	$	$